Key Insights On The Evolution Of Orthoses And Biomechanics

While more research continues to emerge on biomechanics, some physicians feel it is not emphasized enough in podiatry and that other specialists may be gaining more of a foothold in prescribing orthotic devices. Accordingly, expert panelists discuss these controversial issues and examine the potential impact for the profession.

Q: With much emphasis in our podiatry journals on surgery, where and how do you see biomechanics in our profession evolving?

A: As David Levine, DPM, CPed, notes, orthotic devices came of age in the 1970s in the podiatry profession. He says at that time and for several years thereafter, biomechanics and orthotic devices became mainstays of podiatry. In later years, Dr. Levine notes that podiatrists became more drawn to surgery with enhancements in surgical techniques and the growth in the number of procedures DPMs could perform.

“We became enamored by the good and the money that came with foot surgery,” says Dr. Levine. “This came at the expense of some of the simpler, less glamorous aspects of the profession.”

Scott Spencer, DPM, expresses surprise that the profession has not “exhausted the surgical avenue and looked to return to understanding the mechanics of the foot and foot function.” While he says there have been new additions to old procedures, Dr. Spencer feels surgical treatment has not drastically changed. [2]

“In the arena of foot mechanics, there are many new and exciting ideas out there that are not getting the exposure that they warrant. There are many journals that provide a great deal of emphasis on biomechanics but they are not read by the majority of practitioners,” maintains Dr. Spencer.

Dr. Spencer says there needs to be a renewed emphasis on understanding the importance and practical application of biomechanics for everyday practitioners. He believes physicians such as Merton Root, DPM, William Orien, DPM, and John Weed, DPM, had such a large impact because they combined biomechanics with practical application, which really got people’s attention.

Doug Richie Jr., DPM, reminds that biomechanics is not just limited to foot orthotic therapy. Even though journals have monthly articles on joint moments, walking and running kinematics, muscle function and pathomechanics of injury, he says most major podiatric scientific meetings ignore these important topics. In addition, Dr. Richie says biomechanics is not taught as extensively in the podiatric medical schools as it was 20 years ago.

“Thus, the field of lower extremity biomechanics has evolved extensively in the past decade while the participation of the podiatric discipline has dwindled,” points out Dr. Richie.

Although orthotic devices are still important, Dr. Levine notes it started to become clear within the last eight to 10 years that orthoses alone could not solve all of the podiatric biomechanical issues that faced the profession.

“The shoe could no longer be ignored. Podiatrists were slow to acknowledge this,” asserts Dr. Levine. “Other specialties could not ignore it. The foot suffering public just wanted relief and usually with surgery as the last resort.”

The therapeutic shoe bill changed the podiatric perspective regarding footwear, concludes Dr. Levine. He says the bill was an eye opener for what one could do for patients using shoes as a treatment modality. He hopes such bills will continue to evolve in a positive way and not just stop with shoes. Dr. Levine emphasizes that the entire podiatric biomechanical arena includes shoes, orthotic devices, shoe modifications and surgery. He feels the best method of re-emphasizing this understanding lies in establishing positive working relationships with other related specialties including pedorthists.

A: Dr. Richie says the fact that lectures on biomechanics at podiatry seminars have vanished means current practitioners will lose touch with new advances in foot orthotic therapy. As a result, he fears foot orthotic therapy will become less prevalent as a conservative intervention for many of the pathologies that DPMs treat. Dr. Richie says the lack of awareness of emerging advances in foot orthotic therapy may cause some podiatric physicians to favor less sophisticated orthotics such as prefabs, drugstore arch supports and felt metatarsal pads.

As Dr. Levine recalls, it was not long ago that orthoses were mainly the domain of DPMs. However, this situation has evolved as other specialties have become prominent. Although other specialists may be attempting to utilize orthotic devices, Dr. Richie says no specialty has the biomechanical knowledge of the podiatry profession.

While other specialties fabricate orthotic devices, Dr. Richie says they do not do so with the thought process and treatment goals that podiatrists offer. He advocates that the profession continue to emphasize attention to biomechanics, overseeing and delegating exactly what needs to be prescribed when it comes to the use of orthotics.

With some of the more current ideas on foot function, Dr. Spencer says a lack of awareness of these emerging concepts may have an impact on modifications and additions to the orthotic device. If practitioners are not overly comfortable with biomechanics, Dr. Spencer says some physicians may allow the orthotic lab to make decisions for them. Although this sometimes does not result in a negative orthotic outcome, Dr. Spencer cautions that it could lead to a less than ideal orthotic prescription.

Dr. Spencer advocates looking into the actual evaluation process of the patient and how DPMs can prescribe a device that will best suit that patient’s pathology. He believes some evidence would be beneficial in convincing practitioners to pay more attention and reinforce their knowledge base in the area of foot mechanics and the foot orthotic prescription.

Q: Since other specialties, and even specialty stores, are dealing with a variety of shoes and inserts, how will this affect the podiatry profession?

A: Often, shoes and inserts are all that a patient needs to address a mechanical problem, maintains Dr. Spencer. Although shoes and inserts may not be the best solution, he says one must be sensitive not only to the patient’s best interests but also to the patient’s best financial interests.

Rather than being wary of shoes and inserts, Dr. Spencer advocates learning as much as one can about them. He feels the profession should start a campaign that podiatrists are the experts on all things related to the foot, including shoes and inserts.

“It has been my experience that when I can discuss a shoe and or insert with more authority and factual information than the shoe salesman, patients will listen and trust me,” notes Dr. Spencer.

Dr. Richie says the selling of orthoses in retail stores helps the profession as such stores raise the public’s awareness of how the placement of orthotic devices in shoes can help achieve better foot health. Dr. Richie adds that if a patient finds that a store bought device is insufficient, the next step will be to contact a podiatrist to dispense a custom device.

However, Dr. Richie notes that the emergence of other specialists in prescribing orthoses may have a negative impact on podiatrist efforts in this arena.

“The fact that other specialties such as pedorthists and physical therapists are dispensing orthotics is a real threat to the podiatric profession,” argues Dr. Richie. He feels that pedorthists and physical therapists take orthotic therapy more seriously than DPMs, adding that they conduct more research and lecture more on orthoses than do DPMs.

“It will not be long before they actually do a better job with this treatment modality than we do,” he says.

The interest in shoes and inserts should have a positive influence on the podiatry profession, according to Dr. Levine. He feels the demand for podiatric services will increase as the public becomes more aware of foot pain and potential solutions. Dr. Levine cautions that one should not adopt a “shortsighted” attitude that other providers are taking the work of podiatrists.

“We are the leaders in the care of the foot in every aspect whether it is surgical or conservative care,” says Dr. Levine. “Even with other players, we still have more knowledge and expertise in the foot, ankle and lower extremity biomechanical issues and will be the directors of foot care for the future.”

Dr. Levine is in private practice and is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is a Past President of the American Academy of Podiatric Sports Medicine.
Dr. Spencer is an Associate Professor of Orthopedics/Biomechanics at the Ohio College of Podiatric Medicine. He is also a Diplomate of the American Board of Orthopedics and Primary Podiatric Medicine.
For further reading, see “Emerging Concepts In Podiatric Biomechanics” in the December 2006 issue or “Redefining Biomechanics Of The Foot And Ankle” in the October 2005 issue.